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			<form id="theform" method="post" action="mailer.php">
			<table id="tabla" width="600" border="0" cellpadding="0" cellspacing="0" align="center">
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		            <td colspan="3"><span class="textoForm">Instituci&oacute;n: </span><input type="text" id="institucion" name="institucion" class="loginbox" /></td>
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		            <td><span class="textoForm">Direcci&oacute;n: </span><input type="text" id="direccioninstitucion" name="direccioninstitucion" class="loginbox" /></td>
		            <td><span class="textoForm">CP: </span><input type="text" id="cpinstitucion" name="cpinstitucion" class="loginbox" /></td>
		            <td><span class="textoForm">Localidad: </span><input type="text" id="localidadinstitucion" name="localidadinstitucion" class="loginbox"  /></td>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailinstitucion" name="emailinstitucion" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonoinstitucion" name="telefonoinstitucion" class="loginbox" /></td>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="2"><span class="textoForm">Profesor/a: </span><input type="text" id="profesor" name="profesor" class="loginbox" /></td>
		            <td><span class="textoForm">DNI: </span><input type="text" id="dniprofesor" name="dniprofesor" class="loginbox" /></td>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailprofesor" name="emailprofesor" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonoprofesor" name="telefonoprofesor" class="loginbox" /></td>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="2"><span class="textoForm">Capit&aacute;n: </span><input type="text" id="capitan" name="capitan" class="loginbox" /></td>
		            <td><span class="textoForm">DNI: </span><input type="text" id="dnicapitan" name="dnicapitan" class="loginbox" /></td>
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		            <td><span class="textoForm">Direcci&oacute;n: </span><input type="text" id="direccioncapitan" name="direccioncapitan" class="loginbox" /></td>
		            <td><span class="textoForm">CP: </span><input type="text" id="cpcapitan" name="cpcapitan" class="loginbox" /></td>
		            <td><span class="textoForm">Localidad: </span><input type="text" id="localidadcapitan" name="localidadcapitan" class="loginbox" /></td>
		          </tr>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailcapitan" name="emailcapitan" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonocapitan" name="telefonocapitan" class="loginbox" /></td>
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		            <td colspan="3"><span class="textoForm">A&ntilde;o de egreso del colegio: </span><input type="text" id="egresocapitan" name="egresocapitan" class="loginbox" /></td>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="2"><span class="textoForm">Integrante 1: </span><input type="text" id="integrante1" name="integrante1" class="loginbox" /></td>
		            <td><span class="textoForm">DNI: </span><input type="text" id="dniintegrante1" name="dniintegrante1" class="loginbox" /></td>
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		            <td><span class="textoForm">Direcci&oacute;n: </span><input type="text" id="direccionintegrante1" name="direccionintegrante1" class="loginbox" /></td>
		            <td><span class="textoForm">CP: </span><input type="text" id="cpintegrante1" name="cpintegrante1" class="loginbox" /></td>
		            <td><span class="textoForm">Localidad: </span><input type="text" id="localidadintegrante1" name="localidadintegrante1" class="loginbox" /></td>
		          </tr>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailintegrante1" name="emailintegrante1" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonointegrante1" name="telefonointegrante1" class="loginbox" /></td>
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		            <td colspan="3"><span class="textoForm">A&ntilde;o de egreso del colegio: </span><input type="text" id="egresointegrante1" name="egresointegrante1" class="loginbox" /></td>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="2"><span class="textoForm">Integrante 2: </span><input type="text" id="integrante2" name="integrante2" class="loginbox" /></td>
		            <td><span class="textoForm">DNI: </span><input type="text" id="dniintegrante2" name="dniintegrante2" class="loginbox" /></td>
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		            <td><span class="textoForm">Direcci&oacute;n: </span><input type="text" id="direccionintegrante2" name="direccionintegrante2" class="loginbox" /></td>
		            <td><span class="textoForm">CP: </span><input type="text" id="cpintegrante2" name="cpintegrante2" class="loginbox" /></td>
		            <td><span class="textoForm">Localidad: </span><input type="text" id="localidadintegrante2" name="localidadintegrante2" class="loginbox" /></td>
		          </tr>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailintegrante2" name="emailintegrante2" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonointegrante2" name="telefonointegrante2" class="loginbox" /></td>
		          </tr>
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		            <td colspan="3"><span class="textoForm">A&ntilde;o de egreso del colegio: </span><input type="text" id="egresointegrante2" name="egresointegrante2" class="loginbox" /></td>
		          </tr>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="2"><span class="textoForm">Integrante 3: </span><input type="text" id="integrante3" name="integrante3" class="loginbox" /></td>
		            <td><span class="textoForm">DNI: </span><input type="text" id="dniintegrante3" name="dniintegrante3" class="loginbox" /></td>
		          </tr>
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		            <td><span class="textoForm">Direcci&oacute;n: </span><input type="text" id="direccionintegrante3" name="direccionintegrante3" class="loginbox" /></td>
		            <td><span class="textoForm">CP: </span><input type="text" id="cpintegrante3" name="cpintegrante3" class="loginbox" /></td>
		            <td><span class="textoForm">Localidad: </span><input type="text" id="localidadintegrante3" name="localidadintegrante3" class="loginbox" /></td>
		          </tr>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailintegrante3" name="emailintegrante3" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonointegrante3" name="telefonointegrante3" class="loginbox" /></td>
		          </tr>
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		            <td colspan="3"><span class="textoForm">A&ntilde;o de egreso del colegio: </span><input type="text" id="egresointegrante3" name="egresointegrante3" class="loginbox" /></td>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="2"><span class="textoForm">Integrante 4: </span><input type="text" id="integrante4" name="integrante4" class="loginbox" /></td>
		            <td><span class="textoForm">DNI: </span><input type="text" id="dniintegrante4" name="dniintegrante4" class="loginbox" /></td>
		          </tr>
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		            <td><span class="textoForm">Direcci&oacute;n: </span><input type="text" id="direccionintegrante4" name="direccionintegrante4" class="loginbox" /></td>
		            <td><span class="textoForm">CP: </span><input type="text" id="cpintegrante4" name="cpintegrante4" class="loginbox" /></td>
		            <td><span class="textoForm">Localidad: </span><input type="text" id="localidadintegrante4" name="localidadintegrante4" class="loginbox" /></td>
		          </tr>
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		            <td colspan="2"><span class="textoForm">E-mail: </span><input type="text" id="emailintegrante4" name="emailintegrante4" class="loginbox" /></td>
		            <td><span class="textoForm">Tel&eacute;fono: </span><input type="text" id="telefonointegrante4" name="telefonointegrante4" class="loginbox" /></td>
		          </tr>
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		            <td colspan="3"><span class="textoForm">A&ntilde;o de egreso del colegio: </span><input type="text" id="egresointegrante4" name="egresointegrante4" class="loginbox" /></td>
		          </tr>
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		            <td colspan="3"><hr /></td>
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		            <td colspan="3"><span class="textoForm">&iquest;El grupo participante  asistir&aacute; a la reuni&oacute;n informativa del Concurso?</span></td>
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		            <td colspan="3"><span class="textoForm">La misma ser&aacute; el 7 de agosto a las 15.30, en la Universidad Austral, en la sede de Av. Juan de Garay 125, Capital Federal, Buenos Aires.</span></td>
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		            <td colspan="3"><input type="radio" name="asistira" value="si"><span class="textoForm">SI</span></td>
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		            <td colspan="3"><input type="radio" name="asistira" value="no"><span class="textoForm">NO</span></td>
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		            <td colspan="3">
		                <input type="submit" id="inscribir" name="inscribir" value="Inscribir" />
		            </td>
		          </tr>
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			<img src="images/fanpage_formulario_30.jpg" width="25" height="63" alt=""></td>
		<td colspan="3" align="center"  background="images/fanpage_fondo_pie.jpg"><span class="pie">Ingresantes a carreras de grado: Av Juan de Garay 125 (C1063ABB) - Buenos Aires - Argentina (54 11) 5921-8000 - &copy;2012 - Universidad Austral</span></td>
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